One reason ObamaCare has held together despite its unpopularity is the phalanx of support from Democrats. They passed it on a partisan basis without a single Republican vote, and they're sticking to it.

So it was news on Thursday when West Virginia Senator Joe Manchin became the first Democrat of note to break with one of ObamaCare's core tenets. The Senator told a media breakfast that he'd vote to support a bill to fund the government that included a one-year delay in the Affordable Care Act's mandate to buy individual health insurance.

"There's no way I could not vote for it," Mr. Manchin said. "It's very reasonable and sensible." He later issued a statement saying the individual mandate shouldn't be used as an excuse to shut down the government, but on the mandate itself he is now committed.

This is progress because a mandate delay may be the price that House Republicans ask in return for an increase in the debt limit or to fund the government. It's eminently fair because it matches the illegal delay in the business mandate to provide health insurance for employees that the Administration announced earlier this year.

One cost of the GOP's internal "defund" blood-letting is that it's taken the political pressure off Democrats from conservative states to repudiate part or all of ObamaCare. It's time to turn up that heat.============================

Friday Digest

THE FOUNDATION

"They define a republic to be a government of laws, and not of men." --JohnAdams

GOVERNMENT AND POLITICS

The Republican Endgame

by Mark Alexander

Despite all the Leftist rhetoric about ObamaCare being "the law which must nowbe funded," it was wholly rejected by Republicans in the Senate and House,along with many House Democrats. Thus, proposals to defund it, delay it oramend it are exactly in line with what our Founders expected legislators to doin the interest of defending and sustaining Rule of Law.

After 41 previous attempts to delay or amend this behemoth, House Republicansattached a "defund" DemoCare condition to its Continuing Resolutionlegislation (CR being that "pass the buck" gimmick to fund government withoutactually passing a budget -- which has not been done since George Bush's lastyear in office). Using the CR to make their case against nationalized healthcare effectively elevated Republican objections above the political din --thanks in large measure to the much-maligned efforts of Sen. Ted Cruz.Republicans had no intention of "shutting down government," but have used theCR to force Democrat votes on defunding, delaying or amending key ObamaCaremandates.

Here is the Republican endgame (yes, there is one, even if GOP "leadership" istrying to catch up with the rank and file): There is a growing grassrootsstorm brewing in opposition to socialized medicine, now that the reality andconsequences of ObamaCare are starting to sink in. Accordingly, somenon-establishment Republicans in the House and Senate have thrown up aDemoCare dare, a measure to defund this job-killing budget-buster, which isreally a strategic long shot effort to delay implementation of the "individualmandate" until after the 2014 election when Republicans believe they will havegenerated enough political opposition to the plan to significantly modifymajor portions of the law. Indeed, Obama has, for political expediency,already unilaterally (and unconstitutionally) delayed implementation of theemployer mandate.

Of course, the House "defund tactic" won't pass the Demo-controlled Senate, soRepublicans are banking that Demo Majority Leader Harry Reid will strip thatmeasure from the current Continuing Resolution and send it back to the House,where Republicans will return a clean CR, but then replace "defund" with"delay" as a condition for raising the debt ceiling, which we hit sometimebetween 17 and 22 October. Additionally, they will return the debt ceilinglegislation to the Senate with a "wish list" of other amendments, which shouldinclude one requiring that all members of the House and Senate and theirstaffs will be subject to all provisions of ObamaCare, as well as other itemsto include tax reform, approval of the Keystone pipeline, regulatory andentitlement reforms including means-tested Medicare, and a "chained" ConsumerPrice Index (CPI).

The delay measure, and most if not all of the other Republican amendments,will be rejected by the Senate, at which point Republicans should get out ofthe way and let the Senate send the Continuing Resolution and the upcomingdebt ceiling legislation to Obama, thus allowing the ObamaCare mandates to gointo effect as scheduled. (There is an old adage: When your adversary isdefeating himself, don't interfere.)

The net effect of the Republican strategy is that, in advance of 2014,Democrats in the House and Senate will have to vote on a lot of measures andthen will have to defend those votes ahead of the 2014 elections. In regard tothe measure to "delay" the implementation of ObamaCare, Demo votes againstthat "compromise" will be judged harshly in states and districts with onlymodest support for ObamaCare, amid growing grassroots protests against Obama'ssocialized medicine scheme.

What will drive those grassroots protests?

Obama, the consummate narcissist, having embraced the name "ObamaCare," willhimself, along with current and future generations of Democrats, suffer areversal of political fortunes after ObamaCare is implemented. Why? Becauseevery American of every political stripe who has any issue with health care,whether a hangnail or heart transplant, a delay in a doctor's office or incritical care for a loved one, will tie blame for their discontent like anoose around the necks of Obama and his Democrats, who were solely responsiblefor forcing this abomination upon the American people. No matter howFab-Tastic ObamaCare may be for some Demo constituencies, Democrats are goingto be the target of every health care complaint.

Even Demo National Committee chair and Florida Rep. Debbie Wasserman Schultzcan see that pitfall from her perspective in the House. She is insisting thatDemocrats "must not treat every minute provision in the law as sacred." Sheadded that Demos "should be open to suggestions for improving the law."

If Republicans successfully herd the inevitable consumer dissatisfaction andanger toward Democrats, the electoral awards will be substantial in 2014, 2016and beyond. Of course, given that establishment Republican have a propensityfor snatching defeat from the jaws of victory, that's a big "if."

Adding to the List of Problems

ObamaCare's exchanges are scheduled to kick off Oct. 1 with the individualmandate going into effect, but they're not ready. And there's anothersignificant problem with the law as written.

Get ready to be blindsided by a barrage of new taxes. $1 trillion worth...

They'll be coming courtesy of the Affordable Care Act, otherwise known as Obamacare.

And they won't just be affecting those who make over $250,000. The bulk of these taxes will be passed on directly to the middle class.

That's because while a majority of these "stealth taxes" were designed to be taxes on businesses, they're actually transferred directly to ordinary citizens.

MORE: How much extra will you have to pay? To see how Obamacare taxes will directly affect your paycheck, go here.

They include the investment income surtax, a Medicare payroll tax, even a "tanning tax" on those who utilize indoor tanning services.

"Many of those [hidden] taxes, especially those on hospitals, insurers and medical device manufacturers, will ultimately be passed on through higher health costs," said Michael Tanner an expert on the healthcare law.

In fact, analysts estimate Obamacare will cost the average taxpayer nearly $6,000 in extra taxes as early as next year.

Obamacare Tax Hikes Stoke Outrage

The new taxes go into effect January 1, 2014. But they are already infuriating millions of Americans.

While even Obamacare detractors applaud the requirement that insurance companies cover pre-existing conditions and put a stop to lifetime caps on benefits, they say these laudable benefits don't compensate for the bills high cost - especially in new taxes.

According to most experts, Obamacare will create a total of twenty new taxes or tax hikes on the American people.

In fact, the Obama administration has already given the IRS an extra $500 million to enforce the rules and regulations of Obamacare.

The new taxes don't bode well for millions of middle-class Americans. Incomes for the rich have soared this decade but middle class workers have seen their wages stagnate and even drop since the 2008 Great Recession.

Many fear Obamacare with its high insurance costs and new taxes, could provide the middle class a fatal blow.

The 20 new Obamacare taxes are making Americans eyes pop out in disbelief. Take a look.

Of course, the Obamacare plan was primarily designed to decrease the number of uninsured Americans and reduce healthcare costs.

Many experts are saying it will have the exact opposite effect.

That's just one of the reasons why Republicans hope to defund Obamacare before January.

They claim that the taxes and costs needed to pay for Obamacare will crush the middle class and most U.S. taxpayers, as well as trigger job losses in affected industries.

Tax experts say you should try to estimate how much you will have to pay when the law goes into full effect - and take precautions to limit the damage to your bottom line.

What the Experts Say: How to avoid getting your financial neck broken by Obamacare... Watch this video.

One expert, Dr. Betsy McCaughey, a constitutional scholar with a Ph.D. from Columbia University, recently wrote a best-seller showing Americans how they can not only survive Obamacare, but prosper through it.

McCaughey claims to be one of the only people in the country - including members of Congress - who has actually read the entire 2,572 page law.

Her book, titled Beating Obamacare: Your Handbook for Surviving The New Health Care Law, breaks the huge bill down into 168 pages of actionable advice.

The book, written in an easy going, easy to read style, shows some startling facts about Obamacare not seen in the mainstream press.

For example, she points to a little known passage in the bill that shows how you could get slapped with a $2,000 fine for not having health insurance - even if you do actually have it.

She also goes into detail explaining how a third of all U.S. employers could stop offering health insurance to their workers.

In one chapter, she shows how ordinary Americans will get stuck paying for substance abuse coverage - even if they never touched a drink or drug in their life.

According to McCaughey's research, senior citizens will get hit the hardest.

Hip and knee replacements and cataract surgery will be especially hard to get from Medicare in the months ahead thanks to Obamacare, according to McCaughey.

She warns seniors to get those types of procedures done now before Obamacare goes into effect January 1.

Editor's Note: Real facts and figures about the hidden Obamacare taxes and fees and how they will affect everyday Americans and seniors are hard to find. As a courtesy, Money Morning is giving readers a free copy of Betsy McCaughey's new book Beating Obamacare: Your Handbook for Surviving The New Health Care Law. But only a limited number of copies are available. Please go here to reserve yours today.

Today, Obamacare’s October 1 launch date finally arrived. Ever since its passage, supporters of the law have made countless attempts to convince the American people of its viability, dismissing predictions of lost jobs, decreased hours, and rising costs, among others.

Yet from major corporations to local mom-and-pop shops, from entire states to tiny school districts, a wide range of companies and institutions have seen Obamacare’s negative impact on their workers, budgets, and production. Here are 100 examples of how Obamacare is falling short of what was promised.

(Note: Some items on this list came via Investor’s Business Daily and the Heritage Foundation.)

Corporations

1. IBMEarlier this month, the computer giant, once famed for its paternalism, announced it would remove 110,000 of its Medicare-eligible retirees from the company’s health insurance and give them subsidies to purchase coverage through the Obamacare exchanges. Retirees fear that they will not get the level of coverage they are used to, and that the options will be bewildering.

2. Delta Air LinesIn a letter to employees, Delta Air Lines revealed that the company’s health-care costs will rise about $100 million next year alone, in large part because of Obamacare. The airline said that in addition to several other changes, it would have to drop its specially crafted insurance plans for pilots because the “Cadillac tax” on luxurious health plans has made them too expensive.

3. UPSFifteen thousand employees’ spouses will no longer be able to use UPS’s health-care plan because they have access to coverage elsewhere. The “costs associated with the Affordable Care Act have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost,” the delivery giant said in a company memo. The move is expected to save the company $60 million next year.

4. Caterpillar Inc.In the law’s first year, the machinery manufacturer estimated before its passage, Obamacare would add more than $100 million in health-care costs. “We can ill afford cost increases that place us at a disadvantage versus our global competitors,” a Caterpillar executive wrote lawmakers, saying that the law would not meet the goal of providing good, inexpensive health care for all Americans.

5. SeaWorldSeaWorld used to let part-time employees work up to 32 hours per week, but the company is dropping the limit to 28 hours to keep them under the 30-hour threshold at which it would be required to provide health insurance under Obamacare. More than 80 percent of the company’s thousands of employees are part-time and/or seasonal.

Medical-Device Tax

6. Stryker Corp.Stryker Corp., a Michigan medical-device manufacturer, laid off about 1,000 employees earlier this year due to the Affordable Care Act’s 2.3 percent excise tax on medical devices. The company estimated that the tax would cost it approximately $100 million next year. “Stryker remains significantly concerned with the upcoming medical device excise tax and its negative impact on jobs and innovation and will continue to work with Congress to try to repeal the tax,” said the company’s CEO.

7. Welch AllynThe manufacturer announced that it will have to cut approximately 10 percent of its 2,750 employees, 275 in all, because of the medical-device tax. The company also plans to consolidate manufacturing centers, moving some operations from Beaverton, Ore., to its facility in Skaneateles Falls, N.Y.

8. Smith & NephewThe British company informed nearly 100 employees at its Massachusetts and Tennessee facilities that they would be laid off “in order to absorb [the] cost burden” of the tax on medical devices.

Hospitals, Nonprofits

9. Cleveland Clinic, OhioOne of the world’s best-known hospitals announced in September that it would slash jobs and up to 6 percent of its annual $6 billion budget in anticipation of costs associated with Obamacare’s implementation. A spokeswoman for the clinic announced that approximately $330 million would be cut, but she did not say how many of the 44,000 employees the clinic would let go. The Cleveland Clinic is Cleveland’s largest employer and the second-largest employer in Ohio.

10. Wake Forest Baptist Medical Center, North CarolinaLast November, the Wake Forest Baptist Medical Center, in Winston-Salem, announced that 950 full-time-equivalent positions would have to be eliminated in order to make up costs from the health-care law.

11. Orlando Health, FloridaIn that same month, the Orlando Health hospital system announced the biggest staff reduction in its almost century-long history, as part of a “broader effort” to manage the effects of Obamacare, according to the Orlando Sentinel. Orlando Health will cut as many as 400 jobs across the system, in areas ranging from administrative departments to children’s hospitals.

12. Louisiana State University HospitalsIn the same article, the Sentinel noted that LSU hospitals would cut nearly 1,495 positions in order to save $150 million, apparently because of expected reductions in Medicare and Medicaid payments.

13. Delaware HospiceDue to new interpretations of the rules for reimbursing for hospice services, Delaware Hospice, the Ocean State’s only not-for-profit hospice provider, had to let 52 employees go earlier this year. “It’s really health-care reform in action,” a spokeswoman said. “This is affecting hospices across the country. We’re working through dramatic changes in terms of the hospice-care benefits.”

14. Lawrence + Memorial Hospital, ConnecticutThe New London hospital announced earlier this month that Medicare cuts programmed into Obamacare had led to the firing of 33 employees. “L+M and other hospitals are contending with massive structural changes that are happening very rapidly,” the hospital’s president and CEO said.

15. Clifton Springs Hospital, New YorkFifty-eight non-clinical employees were let go from Clifton Springs Hospital in Rochester as the hospital prepared for the changes spurred by the Affordable Care Act. “No one really knows what the impact will be because it really is a very new way for reimbursing for health care,” the hospital’s CEO told a local news station. “So I think everyone is trying to prepare for a change, and a change with less revenue.”

16. Anthem Blue Cross Blue Shield, New HampshireThe state’s only insurer approved to offer plans on the health-insurance exchanges in New Hampshire has cut the number of hospitals that will participate in the plan from 26 to 14 in order to reach “affordable premium levels,” according to the New Hampshire Union Leader.

17. Mexican American Opportunity Foundation, CaliforniaThe nonprofit, which looks after 1,100 pre-K children at its eight Southern California child-care centers, has had to reduce the hours of dozens of employees who used to work 30 to 40 hours per week. “We’re fearful it’s going to be hard to negotiate health care in any contract,” one local labor leader said. “Overall [Obamacare] is a positive step, but on a micro level it’s not all roses.”

18. Carnegie Museum, PennsylvaniaA Pittsburgh news station reports that the Carnegie Museum “reluctantly” scaled back the hours of 48 of its 600 part-time employees to less than 30 hours a week to sidestep the mandate to provide health-care coverage.

19. Fort Smith Area Agency on Aging, ArkansasThe nonprofit revealed that all of its health aides and drivers will work a maximum of 28 hours a week, and that the plan it would offer to its remaining full-time employees would be “bare bones.” To make up for additional Obamacare costs, the organization is asking employees to take steps to save money, such as changing vehicle oil after 5,000 miles rather than 3,000.

20. Emory Healthcare, GeorgiaA news station in Atlanta reports that Emory Healthcare, the state’s largest health-care system, will lay off more than 100 employees, in part because of Obamacare.

21. CoverTN, TennesseeThousands of Tennesseans will lose their coverage under the state’s health-insurance program because it does not meet Affordable Care Act standards for yearly expenditure caps. CoverTN, which was used mainly by small businesses, had a $25,000 yearly benefits limit. “It was all I had,” one Nashville small-business owner said.

State and Local Governments

22. State of VirginiaIn February the General Assembly affirmed Governor Bob McDonnell’s decision to limit the state’s part-time employees to 29 hours per week.

23. Township of Middletown, New JerseyMiddletown has also cut the hours of 25 part-time public employees. “Any of those expenses [for insurance] are going to be passed along to the taxpayers, and so in order to avoid having to do that, we chose to modify the work hours,” said the township’s administrator.

24. Brevard County, FloridaBrevard County’s insurance director told a local television station that the county’s 300-plus part-time employees will be “capped at something less than 30” hours to save the county about $10,000 per employee in health insurance.

25. Township of Berkeley, New JerseyThe Sandy-hit Jersey Shore town said it will “take a hard line” in union negotiations in limiting part-time employees’ hours, because additional health-care costs “are out of the question.” “If it came down to shaving hours to save substantial dollars, that’s something that would have to be considered,” the township administrator said.

26. Chesterfield County, VirginiaAn administrator with this southern Virginia county told the Richmond Times-Dispatch that “several hundred” part-time employees could have their hours cut back to 28. Most of the employees affected would be from the Department of Mental Health Support Services.

27. City of Lynchburg, VirginiaAbout 40 percent of the city’s part-time work force saw cuts to their weekly hours to ensure that their totals come in below the 30-hour threshold, according to the local News & Advance. The city’s human-resources director said some departments do not have the financial resources to add employees or raise wages to make up for the lost work time.

28. City of Mason, OhioCut hours for 200 part-time workers or take a $3.4 million hit: That was the decision the southwestern Ohio city faced when it started weighing Obamacare’s impact. It opted for the former. Part-timers had regularly worked more than 30 hours, but the city manager told the JournalNews that their weekly workload has been reduced to 20 hours.

29. Township of Toms River, New JerseyGovernment workers in Toms River pushing the 30-hour threshold will be bumped down to “below 25” to ensure that they are considered part-time employees, according to the Asbury Park Press. “I think this was not very well thought out,” the township’s business manager said of the Affordable Care Act. “There was this fallacy that the law provisions didn’t apply to municipal government. It sure does.”

30. Lee County, IowaLee County “could be out a lot of money,” a local newspaper reported a supervisor saying, if the county doesn’t stick to its new policy of holding part-time workers to 28 hours.

31. City of Faribault, MinnesotaEmployees working 30 to 38 hours per week with the Minnesota city will be bumped down to part-time status to avoid penalties and costs associated with the mandate.

32. Kansas Turnpike AuthorityThree eight-hour shifts per week: That’s the new maximum schedule for part-time toll collectors in Kansas. While the state’s turnpike authority previously had part-time employees who worked more than 30 hours a week, a new policy will limit them to the new schedule.

Education

33. University of VirginiaBecause of an additional $7.3 million in health-care costs next year, the University of Virginia alerted some of its employees that it will no longer offer health insurance to their spouses.

34. Community College of Allegheny County, PennsylvaniaThe Pittsburgh-area community college informed about 400 part-time employees that they would see a reduction in their hours starting in January of this year to comply with Obamacare regulations. The school had to make this change a year before the law went into effect because Obamacare stipulates that the federal government must look back one year to determine an employee’s status.

35. St. Petersburg College, FloridaTo avoid paying an additional $777,000 per year, St. Petersburg College told 250 adjunct professors that their hours would be cut back for upcoming terms. “I never thought it would impact me directly,” a math teacher told NBC News Investigations. “I was stunned when I got the email. . . . I love teaching at St. Pete College, but that is a significant cut.”

36. Hillsborough Community College, FloridaHillsborough Community College may have to cut the hours of nearly 10 percent of its part-time work force, according to the Tampa Tribune. By keeping those employees under 30 hours per week, the college can avoid an additional $863,500 in total costs for health plans.

37. Hamilton Township School District, New JerseySubstitute teachers will see their time in the classroom limited to four workdays per week, the cap set in place in June by the school district . The “strict limits” went into effect at the beginning of this school year. According to a report by the Trenton Times, other nearby districts also could consider similar provisions.

38. Purdue University, IndianaDespite “pretty radical changes” to the university’s health-care plans for its roughly 27,000 employees, Purdue University still won’t be able to skirt $2.8 million in additional costs brought on by the Affordable Care Act.

39. Oneida Special School District, TennesseeMost of the non-certified personnel in the Oneida Special School District, such as teacher assistants, janitors, and cafeteria workers, will not be allowed to work more than 29 hours a week.

40. Central Michigan UniversitySome of the 5,700 students hired as employees by Central Michigan University will be barred from working more than 25 hours a week. While students have said the new limits “will sting a little bit” and make it “increasingly harder” to pay for various expenses, CMU’s human-resources vice president told a local news station that the move would “align us with other schools” making similar adjustments. Without the limits, CMU would have to pay as much as a $5 million penalty for not offering student workers health-care coverage.

41. University of North AlabamaGraduate-student workers at this school in Florence, Ala., will be barred from working more than 29 hours a week.

42. Arizona State UniversityAssociate faculty members will be limited to teaching six credit hours, or two classes, per semester as part of an effort to more clearly define full-time versus part-time faculty, according to the Arizona Republic. “It’s like getting a punch in the stomach,” said one religious-studies teacher. “For some people it’s a major financial setback.”

43. Ivy Tech Community College, IndianaIvy Tech Community College, where 60 percent of the professors work part-time, will limit its part-time professors to less than 30 hours per week.

44. Maricopa Community Colleges, ArizonaThe Phoenix community-college system notified almost 700 adjunct professors and 600 other part-time workers of a new policy that will prevent them from working more than 30 hours a week. An adjunct professor said the changes would affect his personal finances, and he warned that “this is going to come back to bite us” because instructors won’t be able to fill in for one another due to the cap on hours.

45. Granite School District, UtahFacing at least $14 million in additional health-care costs, the Salt Lake City–area school district, which operates 92 schools, reduced the hours of as many as 1,200 part-time workers. In a letter, the district warned that employees who violate the 29-hour limit for part-time work could be terminated.

46. Alpine School District, Utah“I would have to look for another job, or we would lose our house,” a school-bus driver told Provo’s Daily Herald after the school district said hourly employees could no longer work more than 27.5 hours per week. “If they cut our hours to 27, we will be up the creek,” another driver said.

47. Fort Wayne Community Schools, IndianaIn May, 610 part-time teaching aides and cafeteria workers were informed by the Fort Wayne Community Schools that their hours would be cut to keep FWCS from having to provide health insurance to those employees. “It’s something that almost all employers with part-time employees are trying to resolve,” a district administrator said.

48. Papillion–La Vista School District, NebraskaThe Affordable Care Act would have added $2.5 million in new health-care costs — or $3.4 million in penalties — to the Papillion–La Vista school district if 281 part-time employees’ hours had not been limited to fewer than 30 a week.

49. University of Akron, OhioAlready facing a budget deficit, the University of Akron will ask 230 of its part-time faculty members to accept a cut to their work hours to avoid having to provide health insurance.

50. Youngstown State University, OhioThe university warned part-time faculty members that they will be fired if they surpass the new 29-hour-per-week restriction. “If you exceed the maximum hours, YSU will not employ you the following year,” the school said in an e-mail. “We will have no recourse.”

51. Tredyffrin-Easttown School District, PennsylvaniaIn June, the district announced that it would have to “restructure hours” to avoid cost increases to health-insurance plans. A local newspaper detailed a handful of options for the district; almost all resulted in fewer hours for lower pay.

52. Southern Lehigh School District, PennsylvaniaThe Lehigh Valley–area district reduced the hours of 51 part-time workers to comply with the 30-hour threshold. The cuts will affect employees across the district, including custodians, cafeteria workers, secretaries, health-services support-staff members, and special-education support employees.

54. Spartanburg Community College, South CarolinaAdjunct faculty members taught more than half of the community college’s classes, and all but 23 of the 400 to 500 such faculty members will see their hours slashed to meet the part-time requirement. Otherwise the college would face the choice of paying penalties of up to $2,000 per employee to whom it didn’t offer health coverage or paying up to $1 million for insurance.

55. Finger Lakes Community College, New YorkThe upstate New York community college has set the maximum weekly work hours for adjunct faculty members at “under 30.”

56. Mount Ephraim School District, New JerseyAt a school-board meeting this year, the district announced that the cost of benefits will rise by 18 percent because of the Affordable Care Act, and the increase will be passed on to taxpayers.

57. Minocqua-Hazelhurst-Lake Tomahawk School District, WisconsinThe northern Wisconsin school district took steps to ensure that its part-time employees work fewer than 30 hours per week, a local news station reported.

58. Rock Valley College, IllinoisAs of July, the two-year Rockford school now hires new employees to work a maximum of 25 hours per week.

Big Labor

59. Teamsters, UFCW, and UNITE HEREThe heads of the International Brotherhood of Teamsters, the United Food and Commercial Workers, and UNITE HERE wrote to Democratic lawmakers in July to warn that Obamacare would “destroy the foundation of the 40-hour work week that is the backbone of the middle class.” While the labor leaders acknowledged their past support for the law, they remarked that their decision had “come back to haunt us.”

60. AFL-CIOIn an interview with Al Jazeera America, AFL-CIO president Richard Trumka conceded that the Affordable Care Act “does need some modifications to it” because companies are “restricting their workforce to give workers 29 and a half hours so they don’t have to provide them health care.”

Restaurants and the Food Industry

61. Cheesecake FactoryThe chain restaurant’s CEO warned that while his company already covers its employees who work at least 25 hours, he expects the new law to “be very costly” for most companies. He predicted that if Cheesecake Factory has to expand coverage, the costs will be passed on to consumers with price increases or a lower level of service.

63. Buca di BeppoBuca di Beppo employees across the country say managers told them in June that they would see their weekly hours reduced to less than 30. The founder of the company that owns the restaurants distanced himself from the comments, but employees insist that the Affordable Care Act is the root cause: “I guarantee you it has to do with what’s going on with our country and decisions being made with Obamacare,” said one worker.

64. FatburgerThe CEO of the burger-joint chain announced that franchises have begun making efforts to keep employees under the 30-hour threshold, including some franchises’ engaging in “job sharing.” For example, an employee at one Fatburger could work 25 hours a week at one location, and another 25 hours at a different location with a different owner, without falling under the Obamacare mandate.

65. Wendy’sAn Omaha Wendy’s franchisee alerted almost 100 non-management workers that their hours would be reduced to 28 per week in order to comply with Obamacare mandates.

66. Subway restaurants, IllinoisEmployees at 15 Subway restaurants in central Illinois have begun to see a reduction in their hours. “We don’t like doing that,” the owner said. “But if we were to have to pay for everyone to have health insurance or pay the full penalties, we would be out of business.”

67. Subway restaurants, MaineThe owner of 21 Subway franchises in Maine told 50 of his workers that their hours would be reduced to a maximum of 29 a week. “To tell somebody that you’ve got to decrease their hours because of a law passed in Washington is very frustrating to me,” he told NBC News Investigations.

68. PoFolks restaurant, AlabamaThe restaurant’s owner told a local news station that he will have to cut the number of full-time employees from 16 workers to four to meet the “great challenge” Obamacare poses to the company.

69. Joe Bologna’s, KentuckyIn order to limit employees’ hours and save money, a Lexington businessman has closed his restaurant on Mondays. He told a local news station that additional costs, which could be as high as $20,000, probably would have to be passed on to customers.

70. Five Guys franchises, North CarolinaThe owner of eight Five Guys franchises in the Raleigh-Durham area said he will have to use all the profits from one of his eight stores just to cover “any added costs [that] are going to have to be passed on” by the health-care act.

71. Charco Broiler, ColoradoThe Fort Collins restaurant informed three full-time employees that they would drop down to part-time work to keep the company under the 50-employee threshold, above which employers must insure all full-time employees.

72. Shari’s restaurant, OregonA Portland-area waitress told a news station that she has struggled to pay her bills after Shari’s relegated her status to part time due to one of the law’s mandates, cutting her schedule by almost ten hours a week.

73. Russ’ Restaurants, MichiganNon-managerial employees are no longer allowed to work more than 25 hours per week.

74. Burger King, Washington, D.C.“I’m not sure if Congress understood the devastating effect that this will have on businesses and on employment,” said a human-resources officer for the Maryland-based company that owns Washington, D.C.’s largest Burger King franchise. From the beginning of this year, the company has hired only part-time employees, who are “guaranteed no more than 29 hours per week.”

75. Taco Bell, OklahomaNo employees at the Guthrie Taco Bell will be allowed to work more than 28 hours a week, resulting in a $200 reduction in one employee’s paycheck. “Several of the other people I work with, some of them are single parents, and we do the best we can, and 28 hours a week just isn’t going to cut it for the bills,” the worker said.

76. A Virginia Beach restaurant, VirginiaThe owner of a Virginia Beach restaurant and catering company told Bloomberg that he has stopped hiring people to work full time and is even drawing back on part-time employees’ hours. “I can’t afford health insurance for everyone,” he said.

77. Jim’s restaurants, Texas

The San Antonio restaurant chain might be required to pay as much as $1 million more annually after Obamacare takes effect. In response, Jim’s, like many other companies, is considering a reduction in employees’ hours so it won’t have to provide them with insurance.

78. CiCi’s Pizza restaurants, TexasBob Westbrook owned the state’s three top-performing CiCi’s Pizza franchises but calculated that the costs of providing health care under the employer mandate would leave him about $78,000 in the red at the end of the year. Ultimately, Westbrook figured, it was most cost-effective for him to sell his franchises, after nearly 20 years.

Grocery Chains

79. Whole Foods MarketThe CEO of Whole Foods may not know exactly what changes will take place when the Affordable Care Act is fully implemented, but he’s sure it will negatively affect workers. While he would like his company to continue offering health insurance to its employees, he said there might have to be a tradeoff in the benefits equation: “That just means there’s less we can pay for wages.”

80. Trader Joe’sEven though it has previously provided health-care coverage for its part-time employees, an uncommon practice in the industry, next year Trader Joe’s will give employees who work less than 30 hours a week $500 to purchase a plan in the upcoming Obamacare exchanges. With federal subsidies and possible earnings from other employment, the company said, workers can find coverage that will be just as good. One employee described her soon-to-be lost coverage as “one of the best parts about the job,” and her reaction to hearing it would be dumped was “pure panic, followed quickly by anger.”

81. WegmansThe New York–based grocery chain announced in July that part-time employees will no longer receive health-care coverage due to Obamacare. Wegmans previously offered insurance to part-time employees working at least 20 hours a week.

82. Trig’s Supermarkets, WisconsinSixty-five percent of the 1,100 workers at the Wisconsin supermarket chain will see their hours reduced to below 30 per week. “Doing nothing was not an option,” an executive with the company said. “Within a year, it would have put us out of business.”

83. Waldbaum’s, New YorkAt least one of the New York City–area supermarket chain’s stores has told employees that they will now be part-time workers, with some seeing a reduction of 20 hours or more from their usual weekly total. Some of Waldbaum’s 100 employees affected by the change are now seeking second or third jobs, according to a local newspaper.

84. Royal Farms, MarylandThe company’s 146 convenience stores in Delaware, Maryland, Pennsylvania, and Virginia are transitioning to an almost entirely part-time work force, reducing even full-timers to fewer than 30 hours a week.

Small Local Businesses

85. Southern Hearth & Patio, TennesseeHealth-insurance costs have more than tripled under the Obama presidency, said the owner of Southern Hearth & Patio in Chattanooga. He’s had to offer smaller bonuses and lower pay raises because of the Affordable Care Act.

86. Tsunami Surf Shop, North Carolina and South CarolinaA manager for Tsunami Surf Shop told a local news station that the company will “have to control the shifts” from now on in order to ensure that employees are working fewer than 30 hours a week.

87. Kerns Trucking, North CarolinaThe family-owned trucking company had to cut insurance benefits for 81 workers to avoid having to pay an additional $100,000 under the law’s tax.

88. AAA Parking, GeorgiaNext year, AAA Parking will move half of its 500 full-time hourly employees (out of a work force of 1,600) to part-time employment. “Our executive team has spent extensive time evaluating the impact of this mandate, and the financial impact for AAA Parking is dramatic,” a company memo explained.

89. Circle K gas station, GeorgiaAn employee at the Savannah gas station told a local news station that a supervisor informed workers that they would now work a part-time schedule due to the mandate.

90. Maritz Research, MissouriThe business-research firm informed its 300 employees in July that, starting next year, the company would have to “proactively manage average hours worked on a weekly basis” and enforce a 25-hour threshold.

Premium Rate Increases

91. CaliforniaIndividual-market premiums in the Golden State could jump as much as 146 percent, according to an analysis of the state’s exchange program by Avik Roy of National Review and Forbes. For example, the cost for a nonsmoking 25-year-old in California who purchases the second-cheapest plan on the exchange would go from $92 to $205.

92. ColoradoColorado’s cheapest health plans, which are generally geared toward younger people, are expected to rise dramatically in price next year, according to The Hill. Consider a nonsmoker under 30 years old. This year, this Coloradan could have purchased the cheapest catastrophic plan for $56 per month; next year, the cost is expected to climb to $135.

93. FloridaFlorida regulators say the average premium for individuals will increase by 30 to 40 percent. For small businesses, the rates will be between 5 and 20 percent higher.

94. MassachusettsAccording to a study by the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts, well over half of the state’s small businesses will see a rate increase, with some prices potentially doubling.

95. New MexicoIn a study conducted by the Manhattan Institute for Policy Research, by a team including our own Avik Roy, New Mexico was rated the state that would see the largest average hike in premium costs, at 130 percent.

96. OhioThe cost of the average health-care plan in Ohio is expected to nearly double under Obamacare, according to state insurance regulators. The Hill reports that an 88 percent increase will ultimately mean the cheapest plan on the market after the law goes into effect next year will cost about $280 a month.

97. OklahomaIn all but one of the insurance plans offered to Oklahoma state employees, premiums will go up by as much as 12 percent; the one plan that does not have an increase is the “cheapest, most basic health plan,” according to The Oklahoman. According to an administrator with the state’s Office of Management and Enterprise Services, a tax associated with Obamacare has led to an increase in the plans’ cost.

98. Rhode IslandAccording to the state’s health-insurance commissioner, the rate increase for large employers for 2014 will be about 10 to 12 percent, twice as high as the increase this year.

99. WashingtonThe analysis by Avik Roy and the Manhattan Institute indicates that Washington State residents across all age groups will see significant increases in their rates. Twenty-year-olds will see an average increase of 80 percent; 40-year-olds 50 percent; and 64-year-olds 59 percent.

100 WisconsinThe state’s health-insurance regulators determined that “premiums will increase for most consumers” in Wisconsin when the law goes into effect in 2014. Young residents will see an estimated 125 percent increase, while seniors will pay as much as 45 percent more.

So the standoff continues. But there are signs the terrain of battle has shifted so much that Obamacare -- the reason Republicans fought so hard over resolutions to fund the government in coming months -- is no longer the central issue in the fight.

As the shutdown took hold, the House GOP leadership changed course from trying to limit Obamacare to an effort to mitigate the effects of the shutdown. Boehner and his colleagues came up with bills that would fund the National Park Service, the Department of Veterans Affairs, the Smithsonian, the National Gallery of Art, the Holocaust Museum, and the District of Columbia government. The bills were considered under special rules, which in the end meant that House Democrats were able to kill them -- before Senate Democrats could kill them.

What distinguished the House agenda on Tuesday was that it wasn't about Obamacare. The parks bill, for example, did not contain a provision to defund or delay the president's national health care plan. The Smithsonian bill didn't either. And so on. One could argue that with the government shut down, Obamacare was effectively defunded, at least for the many days the government remains closed. But the fact is, on Tuesday the Republican focus shifted from going after Obamacare to trying to undo the most visible negative consequences of the shutdown.

The lawmaker, who spoke on the condition of not being named, said Mr. Boehner indicated he would be willing to violate the so-called Hastert rule if necessary to pass a debt limit increase. The informal rule refers to a policy of not bringing to the floor any measure that does not have a majority of Republican votes.

"The Democrats' reform of the health care system is stumbling into a predictable and predicted morass. Democrats will inevitably conclude that this calls for even more government. Republicans should side with consumers."

Probably most if not some Democrats have already concluded more government is needed. Obama himself is long ago on record stating single payer is the best. I agree with Mona that Democrats will go after insurance companies (Hillary redux) in 2016. I would only add that this is by design. Part of the plan from the get-go. She makes a good point that Republicans should be ready for this. I nominate her to take over for Rove.

Want a glimpse of what the Obamacare battle will look like in 2015? Just glance at liberal websites. You'll find a trove of insurance company bashing. Are insurance premiums rising instead of falling by the $2,500 per family that Obama repeatedly promised in 2009? They are. If you consult ThinkProgess, Daily Kos and Physicians for a National Health Program, you'll learn that it's the "greedy insurance companies" that are causing prices to rise, not the risibly titled, "Patient Protection and Affordable Care Act."

You can take this to the bank: In the run-up to the next presidential election, Democrats will be in thorough blame-shifting mode. It wasn't the perverse incentives, byzantine complexity, new taxes and layers of bureaucracy built into Obamacare, they'll insist. It was heartless health insurers who were willing to let people die rather than accept a lower profit margin.

Obama has already shown the way. Stumping for Obamacare in 2010, he said, "(They'll) keep on doing this for as long as they can get away with it. This is no secret. They're telling their investors this — 'We are in the money. We are going to keep on making big profits even though a lot of folks are going to be put under hardship.'"

That's just the way businessmen talk, isn't it? Only in the imaginings of the anti-business left. In any case, the other shoe to drop, after the demonization of the industry, will be the same solution Democrats propose for everything — more government. Obamacare will be said to have failed because private companies put profits ahead of people. The "solution" will be single-payer.

Let's not weep for the health insurance companies. They could have energetically opposed Obamacare, and they chose not to. As Timothy Carney of the Washington Examiner explained, it was in their interest to support a law that would 1) require everyone to purchase their product and 2) provide subsidies directly to insurance companies to help people pay for it. As Carney wrote: "Would you be surprised to hear of corn farmers supporting ethanol subsidies?" There were aspects of the law the insurance industry protested, but for the most part, they were content to be tamely transformed into a regulated public utility.

The health care system that predated Obamacare was already so distorted by government subsidies, regulations and tax incentives as to be quasi state-run. True reform would rip that government IV out of the nation's arm altogether and encourage more competition, not less. True reform would remove the tax deductions handed to employers 60 years ago and give them to individuals instead. True reform would permit individuals to shop nationwide for the best plan and would permit companies to offer truly catastrophic plans for the young and healthy. True reform would create high-risk pools to provide for those with chronic conditions.

As the examples of the insurance industry and the corn growers demonstrate, it's a mistake to rely on the business sector to promote free enterprise. Some businessmen do, but many are happy to engage in rent seeking from the state. Farmers, universities, banks, construction companies, green energy firms, car companies, the telecommunications industry — the list of supplicants for taxpayer subsidies is endless.

Republicans are perceived (and often see themselves) as the pro-business party. They should think of themselves as pro-consumer instead.

Still, Republicans do understand the basics of supply and demand better than Democrats, and many predicted the problems Obamacare is already experiencing. They understood, as Obama and his supporters apparently did not, that the laws of economics are not optional. You cannot extend health care to 30 or 40 or 50 million people (the number kept changing) who previously lacked it and bring down total health spending simultaneously. You cannot force insurance companies to accept all customers regardless of preexisting conditions and expect that premiums will not rise to cover the expense. Further, once people realize that insurance companies cannot reject them when they become sick, the incentive to purchase health insurance among the healthy population disappears. (The small fine for failure to buy insurance will not compensate.) You cannot mandate that employers with more than 50 full-time employees provide government approved insurance without causing employers to shift to part-time employees or decline to hire. You cannot impose a "Cadillac tax" without employers raising premiums or reducing their coverage.

The Democrats' reform of the health care system is stumbling into a predictable and predicted morass. Democrats will inevitably conclude that this calls for even more government. Republicans should side with consumers.

To find out more about Mona Charen and read features by other Creators Syndicate columnists and cartoonists, visit the Creators Syndicate Web page at www.creators.com.

But one area where the devastating effects aren’t getting much public attention is basic biomedical research. What’s happening to the thousands of researchers and billions of dollars dedicated to understanding human disease and development? I talked to a government biomedical scientist about the shutdown’s effect. Because the scientist was instructed not to speak with the media, this person will remain anonymous. Below is an edited version of what the scientist told me.

But one area where the devastating effects aren’t getting much public attention is basic biomedical research. What’s happening to the thousands of researchers and billions of dollars dedicated to understanding human disease and development? I talked to a government biomedical scientist about the shutdown’s effect. Because the scientist was instructed not to speak with the media, this person will remain anonymous. Below is an edited version of what the scientist told me.

Perhaps they can get temp jobs reinforcing Barry-cades to keep elderly veterans out of public monuments.

Suit In Oklahoma Could Knock Out ObamaCareBy DICK MORRISPublished on TheHill.com on October 8, 2013Printer-Friendly VersionWhy didn't anyone else think of it?

Scott Pruitt, the attorney general of Oklahoma, acting on the research of Jonathan H. Adler and Michael F. Cannon published in the Case Western Reserve Journal of International Law, has brought a new lawsuit, on behalf of the state, against ObamaCare.

Unlike the suit brought by 26 state attorneys general, this lawsuit does not make a constitutional objection to the Affordable Care Act. Instead, it uses the language of the law to challenge the elaborate system of subsidies, tax credits and individual or employer mandates and fines the act has spawned.

Adler and Cannon studied the actual text of the law -- something Congress never did -- and found that it explicitly provided a subsidy only to those who receive their insurance through state exchanges. Indeed, the subsidies and tax credits were intended to be the carrot that induced states to set up exchanges rather than force the feds to set up their own.

The Internal Revenue Service has ruled that the language of the statute should be "interpreted" to extend the subsidies to those enrolled in state or federal exchanges, but that's not what the law says. Section 1401 of the act, according to their article, "authorizes premium-assistance tax credits and makes them available only through state-run Exchanges."

The section says that taxpayers may receive a tax credit only if "the taxpayer is covered by a qualified health plan ... that was enrolled in through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act."

Adler and Cannon argue that "by its express terms, this provision only applies to exchanges 'established by a state' and 'established ... under Section 1311.' Section 1401 further emphasizes that tax credits are available only through Section 1311 exchanges."

The IRS and defenders of the legislation try to stretch the language to imply a mandate to cover those in federal exchanges. Former IRS Director Douglas Shulman, answering a letter from Republican congressmen about whether the subsidies are limited to state exchanges, wrote:

"The statute includes language that indicates that individuals are eligible for tax credits whether they are enrolled through a State-based Exchange or a Federally-facilitated Exchange."

Unfortunately for President Obama, the statute implies no such thing. It is not only silent on any subsidies for federal exchanges, it is clear that the subsidies were intended to encourage states to set up exchanges.

The Oklahoma suit has survived a motion to dismiss and its standing to bring the suit has been affirmed by the District Court. Pruitt hopes for a judgment later this year and feels the case might reach the Supreme Court by late next year.

In the current fight over the government shutdown, Republicans are simply representing the views of the American people. Americans didn't ask for Obamacare, they don't want it, but now their insurance premiums are going through the roof, their doctors aren't accepting it, and their employers are moving them into part-time work -- or firing them -- to avoid the law's mandates.

Contrary to Obama's promises, it turns out: You can't keep your doctor, you can't keep your insurance -- you can't even keep your job. In other words, it's a typical government program, but this one wrecks your health care.

Also, the president did raise taxes on the middle class in defiance of his well-worn campaign promise not to. Indeed, Obamacare is the largest tax hike in U.S. history.

Among the other changes effected by this law are:

-- Obamacare will allow insurers to charge 50 percent higher premiums for smokers, but prohibits insurers from increasing premiums for those with HIV/AIDS.

-- Nationally, Obamacare will increase men's individual insurance premiums by an average of 99 percent and women's by 62 percent. In North Carolina, for example, individual insurance premiums will triple for women and quadruple for men.

-- Health plans valued at $27,500 or more for a family of four will be taxed at a rate of 40 percent.

-- No doctors who went to an American medical school will be accepting Obamacare.

-- A 62-year-old man earning $46,000 a year is entitled to a $7,836 government tax credit to buy health insurance. But if he earns an extra $22 in income, he loses the entire $7,836 credit. He will have more take-home pay by earning $46,000 than if he earns $55,000. (If he's lucky, he already works for one of the companies forced by Obamacare to reduce employees' hours!)

-- Merely to be eligible for millions of dollars in grants from the federal government under Obamacare, education and training programs are required to meet racial, ethnic, gender, linguistic and sexual orientation quotas. That's going to make health care MUCH better!

-- Obamacare is turning America into a part-time nation. According to a recent report by economist John Lott, 97 percent of all jobs added to the economy so far this year have been part-time jobs. Ninety-seven percent! (I'm doubting this number-- I thought it was more like 70%?)

-- Obamacare is such a disaster that the people who wrote it refuse to live under it themselves. That's right, Congress won a waiver from Obamacare.

Responding to the people's will, House Republicans first voted to fund all of government -- except Obamacare. Obama refused to negotiate and Senate Democrats refused to pass it.

Then the Republicans voted to fully fund the government, but merely delay the implementation of Obamacare for one year. Obama refused to negotiate and Senate Democrats refused to pass it.

Finally, the Republicans voted to fully fund the government, but added a requirement that everyone live under Obamacare. No more special waivers for Congress and their staff, and no waivers for big business without the same waivers for individuals.

Obama refused to negotiate and Senate Democrats refused to pass it. So as you can see, Republicans are the big holdup here.

A longtime Democratic operative, Karen Finney, explained the Democrats' intransigence on MSNBC to a delighted Joan Walsh (aka the most easily fooled person on TV) by comparing House Republicans to a teenager trying to borrow his mother's car. "No, I'm not negotiating!" Mother says. "It's MY CAR!"

This wasn't a stupid slip of the tongue that other Democrats quickly rejected. Finney had used the exact same metaphor to a panel of highly agreeable MSNBC guests the day before. (MSNBC books no other kind of guest.) The left thinks the government is their car and the people's representatives are obstreperous teenagers trying to borrow the government. Which belongs to Democrats.

That's not how the Constitution views the House of Representatives. To the contrary, the House is considered most reflective of the people's will because its members are elected every two years.

As a matter of fact, the Republicans who mistakenly assume they have something to do with running the government represent most of the people who pay taxes to run it. So it's more like a teenager who is making the car payments, maintaining the car insurance and taking responsibility for registering the car being told: "It's not your car."

But the Democrats refuse to even negotiate. It's their government -- and if you Republicans think you're going out dressed like that, you've got another thing coming! Needless to say, they absolutely will not consider the Republicans' demand that Democrats merely live under Obamacare themselves.

Instead, Democrats say "the Koch brothers" are behind the effort to defund Obamacare.

They say Republicans are trying to "burn the whole house down" (Rep. Debbie Wasserman Schultz); "have lost their minds" (Sen. Harry Reid); are trying to negotiate "with a bomb strapped to their chest" (senior White House adviser Dan Pfeiffer); are "legislative arsonists" (Rep. Nancy Pelosi); and are engaging in "blatant extortion" (White House press secretary Jay Carney).

The MSNBC crowd calls Republicans "arsonists" every 15 minutes. They ought to check with fellow MSNBC host Al Sharpton. He knows his arsonists! In 1995, Sharpton whipped up a mob outside the Jewish-owned Freddy's Fashion Mart with an anti-Semitic speech. Sometime later, a member of the mob torched the store, killing seven Hispanic employees.

Every single Democrat in the country uses the exact same talking point: We "refuse to negotiate with a gun being held to our head."

Which means that the Democrats will engage in no negotiation at all -- not now, not ever. House Republicans have already passed three-dozen bills defunding, or otherwise modifying, Obamacare. Senate Democrats and liberal commentators had a good laugh at Republicans for passing them. Now they're paying attention!

If you are in the minority of Americans not already unalterably opposed to Obamacare, keep in mind that the only reason the government is shut down right now is that Democrats refuse to fund the government if they are required to live under Obamacare.

The Obama administration has an implementation problem. More than any administration of the modern era they know how to talk but have trouble doing. They give speeches about ObamaCare but when it's unveiled what the public sees is a Potemkin village designed by the noted architect Rube Goldberg. They speak ringingly about the case for action in Syria but can't build support in the U.S. foreign-policy community, in Congress, among the public. Recovery summer is always next summer. They have trouble implementing. Which, of course, is the most boring but crucial part of governing. It's not enough to talk, you must perform.

There is an odd sense with members of this administration that they think words are actions. Maybe that's why they tweet so much. Maybe they imagine Bashar Assad seeing their tweets and musing: ""Ah, Samantha is upset—then I shall change my entire policy, in respect for her emotions!"

That gets us to the real story of last week, this week and the future, the one beyond the shutdown, the one that normal people are both fully aware of and fully understand, and that is the utter and catastrophic debut of ObamaCare. Even for those who expected problems, and that would be everyone who follows government, it has been a shock.

They had 3½ years to set it up! They knew exactly when it would be unveiled, on Oct. 1, 2013. On that date, they knew, millions could be expected to go online to see if they benefit.

What they got was the administration's version of Project ORCA, the Romney campaign's computerized voter-turnout system that crashed with such flair on Election Day.

Here is why the rollout is so damaging to ObamaCare: because everyone in America knows we spent four years arguing about the law, that it sucked all the oxygen from the room, that it commanded all focus, that it blocked out other opportunities and initiatives, and that it caused so many searing arguments—mandatory contraceptive and abortifacient coverage for religious organizations that oppose those things, fears about the sharing of private medical information, fears of rising costs and lost coverage. Throughout the struggle the American people must have thought: "OK, at the end it's gotta be worth it, it's got to give me at least some benefits to justify all this drama." And at the end they tried to log in, register and see their options, and found one big, frustrating, chaotic mess. As if for four years we all just wasted our time.

A quick summary of what didn't work. Those who went on federal and state exchanges reported malfunctions during login, constant error messages, inability to create new accounts, frozen screens, confusing instructions, endless wait times, help lines that put people on hold and then cut them off, lost passwords and user names.

After the administration floated the fiction that the problems were due to heavy usage, the Journal tracked down insurance and technology experts who said the real problems were inadequate coding and flaws in the architecture of the system.

There were no enrollments in Delaware in three days. North Carolina got one enrollee. In Kansas ObamaCare was unable to report a single enrollment. A senior Louisiana state official told me zero people enrolled the first day, eight the second. The founder of McAfee slammed the system's lack of security on Fox Business Network, calling it a hacker's happiest nocturnal fantasy. He predicted millions of identity thefts. Health and Human Services Secretary Kathleen Sebelius—grilled, surprisingly, on "The Daily Show"—sounded like a blithering idiot as she failed to justify why, in the middle of the chaos, individuals cannot be granted a one-year delay, just as businesses have been.

More ominously, many of those who got into the system complained of sticker shock—high premiums, high deductibles.

Where does this leave us? Congressional Republicans and the White House may soon begin a series of conversations centering on the debt-ceiling fight. Good: May they turn into negotiations. Republicans are now talking about a grand bargain involving entitlement spending, perhaps tax issues. But they would make a mistake in dropping ObamaCare as an issue. A few weeks ago they mistakenly demanded defunding—a move to please their base. They will be tempted to abandon even the word ObamaCare now, but this is exactly when they should keep, as the center of their message and their intent, not defunding ObamaCare but delaying it. Do they really want to turn abrupt focus to elusive Medicare cuts just when it has become obvious to the American people that parts of ObamaCare (like the ability to enroll!) are unworkable?

The Republicans should press harder than ever to delay ObamaCare—to kick it back, allow the administration at least to create functioning websites, and improve what can be improved.

In the past the president has vowed he'd never delay. But that was before the system so famously flopped when people tried to enroll. A delay would be an opportunity for the president to show he knows what's happening on the ground, a chance for him to be responsive. It would allow him to say the program itself is good but the technological infrastructure, frankly, has not yet succeeded. This would allow him to look like one thing no one thinks he is, which is modest.

A closing thought on the oft-repeated liberal argument that ObamaCare must stay untouched and go forward as written. They say it was passed by Congress, adjudicated by the courts and implicitly endorsed in the 2012 election; its opponents are dead-enders who refuse to accept settled outcomes.

There was always something wrong at the heart of this argument, and it's connected, believe it or not, to a story involving Johnny Carson. His show was a great American institution. When Carson retired in 1992, David Letterman was assumed to be his heir. Instead, NBC chose Jay Leno. In time Mr,. Leno faltered, and NBC came back to Mr. Letterman, who now was receiving more lucrative offers from the other networks. Everybody wanted him. But it was his long-held dream to host "The Tonight Show," and he anguished. Then, as Bill Carter reported in "The Late Shift," his advisers came to him. "The Tonight Show" starring Johnny Carson doesn't exist anymore, they said. It's gone. It's Jay Leno's show now. If you want to take a lesser deal to be his successor, go ahead. But the old "Tonight Show" is gone.

This helped clarify Mr. Letterman's mind. He went with CBS.

OK, the Affordable Care Act doesn't exist anymore. It was passed and adjudicated, but since then it has changed, and something new taken its place. Hundreds of waivers and exceptions have been granted. The president decided he had the power to delay the participation of businesses, while insisting on the continued participation of individuals. The program debuted and the debut was a disaster and Americans who want to be part of it haven't been able to join.

The ACA doesn't exist anymore. It isn't the poor piece of legislation it was, it's a new and different poor piece of legislation.

All of this is highly unusual. A continuation of unusual would therefore not be out of order. Delay the program. It's a mess and an oppression. Improve it.

Isn't it odd that Democrats have delayed, changed and removed other parts of this but throw a conniption fit when the Republicans try to fund parts of the budget piecemeal.

Isn't it a good thing that each program, even each line item, should have to stand on its own two feet and be reaffirmed in each budget by each chamber? Otherwise, wouldn't government just grow and grow and grow?

Also, it is telling that the Dems know that Republicans delaying it one year means we are trying to kill it. In a way they are admitting that when they pass something that starts small, what they really want a total takeover.-----------------

It bothers me that I don't see privacy issues raised as a major objection. Just the signup site alone is likely to result in millions of identity thefts. Meanwhile thieves across the country are posing as 'navigators' to steal people's most private information.

Combine Obamacare demanding and tracking all things health and financial with the IRS shareware project, NSA merging databases with email, internet and smartphone, and now "Common Core", the vertical and horizontal cradle to grave tracking system from our all-invasive federal education department (I will post more on that separately), the right of privacy is starting to look like a flashing electronic billboard.

Obamacare: The Rest of the StoryBy BILL KELLERPublished: October 13, 2013 164 Comments

Unless you’ve been bamboozled by the frantic fictions of the right wing, you know that the Affordable Care Act, familiarly known as Obamacare, has begun to accomplish its first goal: enrolling millions of uninsured Americans, many of whom have been living one medical emergency away from the poorhouse. You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable.

What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. Irony of ironies, the people who ought to be most vigorously applauding this success story are Republicans, because it is being done not by government decree but almost entirely with market incentives.

Using mainly the marketplace clout of Medicare and some seed money, the new law has spurred innovation and efficiency. And while those new insurance exchanges that are now lurching into business will touch roughly 1 in 10 Americans (the rest of us are already covered by private employer plans or by government programs like Medicare), these systemic reforms potentially touch every patient, every taxpayer.

“This is the 90 percent of the story that doesn’t make the headlines,” said Sam Glick, who follows health care reform for the Oliver Wyman consulting firm.

Since the Affordable Care Act was signed three years ago, more than 370 innovative medical practices, called accountable care organizations, have sprung up across the country, with 150 more in the works. At these centers, Medicare or private insurers reward doctors financially when their patients require fewer hospital stays, emergency room visits and surgeries — exactly the opposite of what doctors have traditionally been paid to do. The more money the organization saves, the more money its participating providers share. And the best way to save costs (which is, happily, also the best way to keep patients alive) is to catch problems before they explode into emergencies.

Thus the accountable care organizations have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups.

These organizations have invested heavily in information technology so they can crunch patient records to identify those most at risk, those who are overdue for checkups, those who have not been filling their prescriptions and presumably have not been taking their meds. They then deploy new medical SWAT teams — including not just doctors but health coaches, care coordinators, nurse practitioners — to intervene and encourage patients to live healthier lives.

Advocates of these reforms like to say that they are transforming medicine from the treatment of disease to the treatment of patients — and ultimately the treatment of populations.

At Cornerstone Health Care, a 250-doctor organization in North Carolina, patients with a history of congestive heart failure get a daily phone call from a nurse asking them to step on a scale and report their weight, the best early indicator of an impending emergency. The next stage, Grace Terrell, the president of Cornerstone, told me, will be to give these patients scales that automatically transmit their weight directly to the nurse. (“If the N.S.A. is Big Brother, we’re Big Mother,” Terrell says of the weight surveillance program.) Diabetes patients are invited in for low-cost pedicures. Why? Because diabetics are notoriously vulnerable to infections that lead to amputation, and a common cause of those infections is ingrown toenails. (Both of these practices were pioneered by CareMore, a California-based company that runs clinics for Medicare patients and that has become a major role model since Obamacare.)

The Heritage Provider Network, a huge accountable care organization in California, offers Medicare patients free dance lessons, healthy cooking classes and casino excursions that feature “brain power” activities on the bus. The Greater Buffalo United Accountable Healthcare Network, a new, seven-doctor practice in upstate New York, is building a gym and a teaching kitchen for its patients, who are mostly inner-city minorities.

“Most doctors were on treadmills,” plodding through their routines, said Raul Vazquez, the chief executive of the Buffalo venture. Now they’re reinventing health care for the inner city with an invigorated sense of mission.

This is not the heroic medicine that turns surgeons into gods and emergency rooms into Hollywood material. Don’t expect to see a toenail-clipping episode on “Grey’s Anatomy.” But these services address the embarrassing fact, reiterated in study after study after study, that Americans pay much more for medical care than other developed countries, with no better results. Obamacare addresses this problem by going, as Willie Sutton famously advised, where the money is. It concentrates resources on the unhealthiest. According to Kaiser Health News, the sickest 1 percent of patients account for 21 percent of health care costs; 5 percent account for half of the total costs. ==================Page 2 of 2)

“There are organizations that are bringing emergency room visits down by 15 to 20 percent,” Glick said. “Hospital admissions, you see numbers like 20 and 30 percent. That can make a huge difference not only in the cost of care but also in the quality of care.”

The best sign that these innovations are beginning to go viral is that they have caught the attention of some giant businesses. Drugstore chains like Walgreens and CVS are now partnering with hospitals or accountable care organizations to give patients convenient points of access and to coordinate treatment. Companies that spend heavily on employee health care plans are learning the best lessons of the Obamacare laboratory. Walmart, the country’s biggest private employer, will fly workers who need transplants or heart or spinal surgery to premier facilities like the Mayo or Cleveland Clinics to assure that their problems get fixed right the first time, avoiding costly readmissions.

Obamacare has also had some important indirect consequences. According to Catherine Dower of the Center for the Health Professions at the University of California at San Francisco, since the Affordable Care Act states have become more aggressive about challenging some of the protectionist laws that prevent well-qualified medical professionals — pharmacists, nurse practitioners, physician assistants, emergency medical technicians — from offering some kinds of primary care. California just passed a law that will allow pharmacists to check your blood pressure and cholesterol level and to dispense prescription birth control and antismoking drugs. Letting pharmacists perform services that don’t require seven years of medical training makes those services cheaper and more convenient, increasing the chances consumers will take better care of themselves.

Dower said that while the formal doctor lobby continues to resist this as a threat to the M.D. cartel, many physicians have embraced it, recognizing that outsourcing some of these services leaves them more time to do what only doctors can do. And with an estimated 29 million new clients expected to join the ranks of the insured, there is a lot of work to share.

The emerging system is far from perfect. As Elisabeth Rosenthal reported in The Times on Sunday, Congress buckled to drug company lobbying and refused to let Medicare use its purchasing power to bring down obscenely inflated drug prices. And like any upheaval, the reform of health care will produce some losers. Not all of the new organizations will make a go of it. Since hospitals account for about a third of our health care bill, they are a particular target of cost-cutters; some will fail to adapt and will go out of business. Taking costs out of the system means taking money out of somebody’s pockets. This is what the business world calls “creative destruction.”

Grace Terrell of Cornerstone said that of its 250 doctors, “20 percent are still, ‘Down with Obamacare,’ though even they like the private-enterprise approach; 30 percent really get it; and the others are moving faster than the market. We may ultimately fail, but we’re pretty far ahead of the curve.”

One reason you may not have heard much about this part of the Obamacare story is that it is numbingly complicated. (Stephen M. Davidson of Boston University has written a concise and accessible guide to the law and its consequences.) But I suspect another reason is partisan spite. The Democrats were passionately in favor of enrolling the uninsured, but many would have preferred a government-run program, or at least a public option. What Obamacare has wrought is the kind of market-driven reformation that Republicans pretend to believe in. Which makes you wonder how much of their opposition rests on the merits, and how much is just a loathing for anything associated with Barack Obama.

Politics and journalism at its very worst. Once the government takes over the rest of healthcare, that is when we will begin to see real improvements in quality and cost containment - just like, um, name one example please of where else that was the case. Housing finance?

Bill Keller, NYT: "Which makes you wonder how much of their opposition rests on the merits, and how much is just a loathing for anything associated with Barack Obama."

Throw it all on the motives of the opponents if you have no other point to make. What total blather! The opposition is based totally on the lack of merits of this disgusting program and the loathing would be exactly identical if it were Hillary, Howard Dean, John Edwards or anyone else doing this. Does Bill Keller really think Republican opposition would be different if we had elected someone else to transform America in the direction of Stalin and Marx? No he doesn't, and he is perfectly comfortable lying to his readers on his central point.

Lower your income, get free Health Care. "If they can adjust their income, they should." "It's not cheating. It's allowed", says Karen Pollitz, a senior fellow with the Kaiser Family Foundation.

Under the Affordable Care Act, if your 2014 income is between 138 and 400 percent of poverty level for your household size, you can purchase health insurance on a state-run exchange (such as Covered California) and receive a federal tax subsidy to offset all or part of your premium.

If your income falls below 138 percent of poverty, you qualify for Medicaid, which provides no-cost health care to low-income people. In California, it's called Medi-Cal.

Lower your income, get free Health Care. "If they can adjust their income, they should." "It's not cheating. It's allowed", says Karen Pollitz, a senior fellow with the Kaiser Family Foundation.

Under the Affordable Care Act, if your 2014 income is between 138 and 400 percent of poverty level for your household size, you can purchase health insurance on a state-run exchange (such as Covered California) and receive a federal tax subsidy to offset all or part of your premium.

If your income falls below 138 percent of poverty, you qualify for Medicaid, which provides no-cost health care to low-income people. In California, it's called Medi-Cal.

Bangor Daily News A Portland, Maine family doctor is the latest poster child for private practitioners who are turning their backs on insurers altogether. In April, Dr. Michael Ciampi stopped accepting all forms of insurance, including Medicare and Medicaid, and started charging for his services a la carte.

"We're asking people to pay at the time of service just like you would pay at your garage or your lawyer or your plumber," Dr. Michael Ciampi told the Bangor Daily News' Jackie Farwell. "Now, I work for patients. I don't work for the government and I don't work for insurance companies."

Primary care doctors are among the lowest paid in the industry, and they've seen big cuts to their bottom line recently, as insurers cap physician fees in order to rein in health care costs. Once Obamacare goes into full effect in 2014, it's predicted that insurance premiums will skyrocket, and all the extra paperwork required will cost private practices like Ciampi's more time, money and manpower.

The Inquisitir explains:

A doctor’s income is what the office takes in payments minus expenses or overhead. Physician overhead cover many things but the most expensive cost is the staff necessary to handle insurance coverage. About 20 to 30 years ago this cost used to be around 15 to 30% of revenue. Now for many doctors this insurance overhead has grown to an outstanding 60% or more, with more staff being hired to handle the quickly enlarging piles of paperwork required by Obamacare.

To top it off, Medicare is beginning to cap payments while the overhead costs remain the same, or worsen. So doctors may stop insurance coverage from Medicare just because they’d see a huge drop in their annual income.

Since the switch, Ciampi says he has been able to slash his prices by half in some cases, just from his overhead savings alone. But he's lost patients in droves, with several hundred of Ciampi's 2,000 patients ditching him altogether.

Nashville, Tenn.-based Dr. Robert Tomsett had similar results after converting to a no-insurance model at his practice in 2011. Unfortunately, his staff paid the price.

"We did have to let some of the existing staff go as our patient count has dropped since initiating our transition to self-pay," Tomsett wrote. "This is typical from accounts by other providers around the country that have converted their practices, some as much as a 75% drop in patient count."

Six weeks into his no-insurance model, Tomsett saw only 75 patients and managed to break even.

"I am able to spend more time with each patient than any other time in my career," he wrote.

In a similar case in San Antonio, Texas, a pair of primary-care physicians made headlines when they stopped accepting third-party insurance a year ago. They told MySanAntonio.com that they moved to a direct pay model because of the " expensive and bloated bureaucracy that drives financial reimbursements."

A 2012 survey of more than 13,500 doctors from around the country found that 26% have already cut services for Medicaid patients due to costs, and within the next two years more than 50% plan to cut some patient access to their services. About 7% plan to switch to cash-only practices, like Ciampi's, or "concierge practices" in which patients pay doctors an annual retainer.

What happens if more doctors follow Ciampi's lead and take matters into their own hands?

You've got a couple of options –– take your business elsewhere or pay the piper. Some insurers will offer partial reimbursements to out-of-network physicians, but the onus will be on you to deal with the paperwork involved.

Zero Alaska ObamaCare EnrolleesThe rollout of the Healthcare.gov ObamaCare exchanges has largely been a technical disaster and utterly ineffective. Very few people are successfully signing up for coverage through the website, though the clock is still ticking on the individual mandate. The latest news is that after two weeks, no one from Alaska has enrolled. Sen. Lisa Murkowski (R-AK) wrote to HHS Secretary Kathleen Sebelius looking for answers: "This system that cost more than $400 million, took three years to build, and was billed as a one-stop shop for individuals seeking health insurance is not working as advertised." That pretty well sums it up.

If you thought the O'care law was complicated enough, consider the regulations that come with it. According to CNSNews, "Bureaucracies in the Obama Administration have thus far published approximately 11,588,500 words of final Obamacare regulations, while there are only 381,517 words in the Obamacare law itself. That means unelected federal officials have now written 30 words of regulations for each word in the law." We're sure our fellow bureaucrats read all this before implementing it, too.

O'Care: 'No Expectation of Privacy'?In the fine print of the ObamaCare web site, at least when it is working, you might want to pay attention to this line from the disclaimer: "You have no reasonable expectation of privacy regarding any communication or data transiting or stored on this information system."

Jim DeMint: We Won't Back Down on ObamaCareFighting a law that is unfair, unworkable and unaffordable is reasonable and necessary.ByJim DeMintOct. 17, 2013 6:27 p.m. ET

Now that the government shutdown has ended and the president has preserved ObamaCare for the time being, it's worth explaining why my organization, the Heritage Foundation, and other conservatives chose this moment to fight—and why we will continue to fight. The reason is simple: to protect the American people from the harmful effects of this law.

I spent a good part of my summer traveling around the country with the Heritage Foundation's sister organization, Heritage Action, and I heard firsthand from many Americans being harmed by ObamaCare. More and more people have had their work hours cut, their jobs eliminated and their coverage taken away as a result of this new law.

Supporters of ObamaCare usually defend the law by insisting that they want to help people. I won't question their motives. I do wonder, however, if they understand what they're doing to the country.

We know that premiums are going up due to ObamaCare—Americans are getting notices in their mailboxes every day. On Wednesday, Drew Gonshorowski of the Center for Data Analysis at the Heritage Foundation published research that shows exchange premiums are going up in all but five states. In North Carolina, for example, many consumers will find their premiums almost double when shopping on the government exchanges. The hardest-hit states, such as Georgia, Arizona, Vermont and North Dakota, will see premium increases of up to 150%.

Mr. Gonshorowski's research shows that the hardest hit by the increases will be young adults. "A state that exhibits this clearly is Vermont," he writes, "where the increase for 27-year-olds is 144 percent and the increase for 50-year-olds is still 60 percent, but far less. All states exhibit this relationship."Enlarge Image

We also know that, once established, the cost of ObamaCare's new entitlements will not fall. Historical evidence suggests the opposite. Nearly 50 years ago, at the time of Medicare's enactment, it was projected that the federal government would spend $9 billion on Part A hospital services in 1990. Actual spending in that year totaled $67 billion—an increase of 644% compared with initial estimates.

Likewise, government officials originally projected that Medicare Part B physician services would require "federal appropriations of about $500 million a year from general tax revenues." Last year, the federal outlay for that program was $163.8 billion—overshooting the original estimate by more than 4,400%.

Given this track record, the Congressional Budget Office's projection that ObamaCare will cost "only" $250 billion (you read that right: a quarter-trillion dollars) a decade from now seems far-fetched.

There's a reason Senate Majority Leader Harry Reid recently claimed that ObamaCare will lead to a single-payer health-care system: It happens to be true. Once employers drop health coverage for their low and middle-wage workers, the majority of Americans will be dumped into tightly regulated health exchanges and granted a "choice" of plans that will be more alike than different. The quality of care will suffer, access to doctors and plans you once had and liked will be reduced, and America will deteriorate into a two-tier health system—one in which the well-off can still buy quality coverage, but most Americans are consigned to poor care through the exchanges and Medicaid.

Yes, I can hear many conservative friends saying to me right around this point: "Jim, we agree with you that ObamaCare is going to wreck the country, but elections have consequences." I have three responses.

The first is that ObamaCare was not the central fight in 2012, much to the disappointment of conservatives. Republicans hoped that negative economic news would sweep them to victory, and exit polls confirmed that the economy, not health care, was the top issue. The best thing is to declare last year's election a mistrial on ObamaCare.

Second, the lives of most Americans are not dominated by the electoral cycle. They shouldn't have to wait three more years for Congress to give them relief from this law, especially when the president has so frequently given waivers to his friends. Full legislative repeal may not be possible while President Obama remains in office, but delaying implementation by withholding funds from a law that is proven to be unfair, unworkable and unaffordable is a reasonable and necessary fight.

There's a third reason not to stop fighting. Forget the consultants, the pundits and the pollsters; good policy is good politics. If the Republicans had not fought on ObamaCare, the compromise would have been over the budget sequester. Instead, they have retained the sequester and for the past three months ObamaCare and its failings have been front and center in the national debate. Its disastrous launch was spotlighted by our defund struggle, not overshadowed, as some contend. With a revived and engaged electorate, ObamaCare will now be the issue for the next few years.

These are the reasons we fought so hard to get Washington to listen to the American people and take action to stop ObamaCare, and it is why so many are thankful for the courageous leadership of people like Sens. Ted Cruz and Mike Lee, and conservatives in the House of Representatives. The law is economically unstable, financially irresponsible and harmful to hardworking Americans.

Mr. DeMint, a former senator from South Carolina, is president of the Heritage Foundation.

O'Care: 'No Expectation of Privacy'?In the fine print of the ObamaCare web site, at least when it is working, you might want to pay attention to this line from the disclaimer: "You have no reasonable expectation of privacy regarding any communication or data transiting or stored on this information system."

Thank you Crafty for catching and posting this. With or without this offensive and stupid message, the loss of privacy and control over your own life with this bad legislation is monumental.

It bothers me that even opponents of Obamacare focus only on the taxes or spending issues. This intrusion is SO much greater than that!

The Affordable Care Act's botched rollout has stunned its media cheering section, and it even seems to have surprised the law's architects. The problems run much deeper than even critics expected, and whatever federal officials, White House aides and outside contractors are doing to fix them isn't working. But who knows? Omerta is the word of the day as the Obama Administration withholds information from the public.

Health and Human Services Secretary Kathleen Sebelius is even refusing to testify before the House Energy and Commerce Committee in a hearing this coming Thursday. HHS claims she has scheduling conflicts, but we hope she isn't in the White House catacomb under interrogation by Valerie Jarrett about her department's incompetence.

The department is also refusing to make available lower-level officials who might detail the source or sources of this debacle. Ducking an investigation with spin is one thing. Responding with a wall of silence to the invitation of a duly elected congressional body probing the use of more than half a billion taxpayer dollars is another. This Obama crowd is something else.

What bunker is Henry Chao hiding in, for instance? He's the HHS official in charge of technology for the Affordable Care Act, and in March he said at an insurance lobby conference that his team had given up trying to create "a world-class user experience." With the clock running, Mr. Chao added that his main goal was merely to "just make sure it's not a third-world experience."Enlarge Image

He didn't succeed. Whatever is below third-world standards would flatter the 36 federally run exchanges as they've started up. But perhaps Mr. Chao or someone else, if not Mrs. Sebelius, can answer even the simple question of how many Americans have managed to enroll for coverage. HHS could easily resolve any confusion but it won't even talk to Democratic allies, friendly reporters and what it calls the insurance industry "stakeholders" that it will need to make ObamaCare work.

No doubt a hearing would be a spectacle—with TV cameras on hand—but Mrs. Sebelius can't hide forever. Even pro-entitlement liberals want to know about what went wrong and why, how much if any progress is being made, and whether the ObamaCare website Healthcare.gov will be usable in a matter of months—or years.

More disclosure might also help HHS preserve a scrap of credibility, given that none of its initial explanations has held up. Right now, no one trusts a word that emerges from Fortress ObamaCare.

To take one example, this week the Associated Press obtained an internal HHS memo from September 5, 2013 specifying the Administration's monthly enrollment targets—a half-million sign-ups in October, 3.3 million by December 31, and so on. Asked about this by AP, HHS not only declined to say if it is meeting its projections. The department issued a statement claiming that "The Administration has not set monthly enrollment targets." The spokesman did not cite the classic Marx Brothers line, "Who are you going to believe, me or your own eyes?"

Eventually Mrs. Sebelius will have to make a real accounting of this government failure to someone other than the TV comic Jon Stewart, and perhaps she can also explain why the people who can't build a working website also deserve the power to reorganize one-sixth of the U.S. economy. For now, the Administration that styles itself as the most transparent in history won't reveal the truth—perhaps because it is afraid of what the public will find.

who was one of the designers of AHA was Britain's National Health Service.In a recent Lancet piece the resigning chair of the Royal College of General Practitioners says that primary care is in crises and headed for collapse. Sounds like here in the US:

*****The continuing haemorrhage of UK general practice

The Lancet

Last week was no doubt a sad one for Clare Gerada, who gave her last Chairwoman's speech before stepping down from leading the Royal College of General Practitioners (RCGP) after 3 years. She has been the most visible and successful head of the College in recent memory. Unlike previous Chairs, Gerada has not been afraid to challenge the Government on a wide range of issues. She has led doctors with more confidence, passion, positive vision, and success than the British Medical Association has ever been able to do. She has been the voice of clinical practice in the community for the tens of thousands of GPs who are at the frontline of primary care and the Coalition's bungled health reforms.

At the RCGP's annual conference in Harrogate, Oct 3—5, Gerada hit out at the Government again. At a time when it had just announced plans to increase GP surgery opening times in England from 0800 h to 2000 h, 7 days a week, she presented alarming new figures from the RCGP that general practitioners (GPs) in the UK face a £400 million “black hole” as a result of funding cuts during the past 3 years. This disinvestment equates to a 7% cut in spending per patient. Gerada pointed out that although GPs saw 90% of patients as the first contact, they received only 9% of the entire UK National Health Service (NHS) budget, and that percentage share was falling. “General practice is in crisis”, she lamented. In recent surveys, 85% of GPs also felt general practice was heading for collapse. Quality and safety of patient care are being put in danger, since GPs are seeing up to 60 patients in an 11 h day with far fewer resources. Many predict that patients will have to wait longer for an appointment in the future. Gerada called for general practice to get at least 10% of the NHS budget and 10 000 more GPs.

The Government and its Health and Social Care Act wanted to make general practitioners the clinical leaders of the NHS. But by by withdrawing investment in primary care they have starved general practice of the resources needed to lead the service properly. The result will not only be an inevitable vacuum in leadership but also serious damage to the care of patients.*****

Perhaps readers might recall how I pointed out how electronic records are simply not ready for prime time. Yes there are hundreds of vendors out there who will sell you that theirs is the one that works great.

But all are clunky cumbersome and frankly a pain in the ass. I recall reading that there was some kick back to the politburo Ivy league know-it-alls. IN one response editorial one of the leading doctor IT cottage industry types basically wrote in his response for us doctors to more or less just stop whining, shut up, and be happy we are getting through the "FIRST PHASE". So now all that IT that is being shoved down our throats is suddenly not the answer but is the first phase.

Now the world with the AHA tech failure can see what we have been living through for the past couple of years. The IT people are already blaming the government on Drudge. Oh they were having to eat pizza and work till 10 etc. No one ever heard a peep from this crowd while they were happily receiving their pay checks probably each and every one of the promising the government they could do the job so they could get the contract.

People, it is all the classic fingers pointing every which way when something is a mess. Don't blame me it is him or her; not me.

Eventually it will be made workable but don't expect any of it to be a breeze. This will take years.

IT does show how government regulations make all of us suffer. While the Obamas of the world promise free health care to all.

Why even that idiot (I have concluded) Peirce Morgan was on last night saying how they have "FREE" health care in Great Britain.

Wow! How do they do that? It's free? Why can't we do what you wizards in Europe do here?

Health Care LinesAccording to a report by The New York Times, as many as 5 million lines of computer code will need to be rewritten before HealthCare.gov works as intended (we'd argue that no amount of rewritten code will make the ACA work, but that's a different discussion). But if 5 million lines of code sounds like a lot (and it is), wait until you hear this: According to one expert familiar with HealthCare.gov, the site's source contains approximately 500 million lines of code. To put that in perspective, the entire Linux operating system kernel that powers the majority of the Web's servers (including HealthCare.gov's) contains just under 16 million lines of code, and is the result of 22 years of ongoing development. The space shuttle's primary flight control system was comprised of 400,000 lines of code. Even Windows XP was built in 45 million lines of code. Once again, we can depend on government (to make things incredibly complicated).

Obamacare's top-down, tax-subsidized, job-killing, privacy-undermining electronic record-sharing scheme has been a big fat bust. More than $4 billion in "incentives" has been doled out to force doctors and hospitals to convert and upgrade by 2015. But favored EMR vendors, including Obama bundler Judy Faulkner's Epic Systems, have undermined rather than enhanced interoperability. Oversight remains lax. And after hyping the alleged benefits for nearly a decade, the RAND Corporation finally 'fessed up that its cost-savings predictions of $81 billion a year -- used repeatedly to support the Obama EMR mandate -- were (like every other Obamacare promise) vastly overstated.

In June, the Annals of Emergency Medicine published a study warning that the "rush to capitalize on the huge federal investment of $30 billion for the adoption of electronic medical records led to some unfortunate and unintended consequences" tied to "communication failure, poor data display, wrong order/wrong patient errors and alert fatigue." Also this summer, Massachusetts reported that 60 percent of doctors could not meet the EMR mandate and face potential loss of their licenses in 2015. And a few weeks ago, the American College of Physicians pleaded with the feds to delay the mandate's data collection, certification and reporting requirements.

Michelle who is one of my favorite writers, indeed if I was younger and she was available....

Yes we on the front lines of medical care are forced to spend ALL our time collecting and responding to data and data points, and formats, and numbers. The personal touch between patient and doctor and decision making is being taken away. Standards are set primarily by government but the big companies are also using the data to extract every single dime out of humanities daily lives.

A case manager at one of the hospitals I go to recently said to me it is all about the data. Everything we do is for the data. Data can be manipulated. It can be falsified. She said if it isn't written in the data - it doesn't exist.

Hospitals, dialysis, pharmacies, pharmacy benefits managers, pharmaceuticals, urgent care centers, nursing homes are all consolidating and being run by big corporations. Most of this is I think funded via Wall Street. One astute physician suggested how health care is one of the biggest and only drivers of the economy right now. So the 1000 dollar suits are focusing on health care. No one can compete with their billions to throw around.

(The energy sector could also do well if the liberal machine would get the hell out of the way.)

There are more jobs there will be more efficiencies. I don't know if care will necessarily be better or not. One definite thing is that the way it is measured will certainly be distorted to reflect that it is.One professor who used to do a lot of research pointed out - it is all in the way one measure it.

The data points that are shoved in front of us are the measurements used to reflect better care. We will not see other issues that are not being measured.

I can go on a hospital floor and see rows of nurses sitting at computers. In some locations I have actually had to scramble to even get to a computer terminal before the nurse gets there. Or vice a versa.

We can see first hand how every single human endeavor is being manipulated to squeeze every single penny out of our existence.

South Carolina Doctor Mike Vasovski has joined a growing group of doctors and taken his medical practice off the insurance grid.

Last week Dr. Vasovski wrote on his Facebook page:

South Carolina Doctor Mike Vasovski"My medical practice has gone off line. Effective yesterday, the computers that contain patient's account information including billing diagnosis, have been completely de-linked from the internet. Therefore, your health information is completely secure. Accounting will be done in house with Quickbooks on a PC that is not connected to the internet. We are moving towards a payment at time of service model in which my practice does not participate with insurance companies. Fees will be truly affordable and your medical records will not be in a format that can be accessed electronically. Peace and Liberty, Dr. Mike Vasovski."

In an interview with Joshua Cook, he discussed a variety of reasons – both ideological and practical – for his choice, and described the effects of these actions on patients. Vasovski showed how such practices could keep a free market healthcare system alive even as Obamacare takes effect.

"Off grid" or "cash only" practices collect money directly from the patient at the time of service. Vasovski described two off grid payment models, one in which doctors charged a per month fee in which people could visit as often as necessary, and one in which there is simply a reasonable office visit charge. Vasovski's practice has chosen the second model with a $45 benchmark, and says that is enough to provide most services because most vaccinations and other shots are being provided by pharmacies.

"So we're not responsible for buying those things, storing them and counting them and that kind of stuff." Adding that cost-saving development to the nearly $6000/year saved on insurance software, this becomes an increasingly viable business model. There is also a huge number of generic drugs – over 300 – available for $4/month at major pharmacies. "That's less than a 6-pack and it gets you a month worth of your medicines."

The direct payment business model has a number of benefits for both practices and patients. One of the most topical is security. Because Vasovski's office isn't connected to insurance companies, he has been able to take his entire practice off the internet. No hackers, Assange-like activists, or government entities can access any patient information, like Social Security numbers or health problems.

Even the most "secure" encryption services cannot provide that assurance. He even described a telephone call in which a salesperson tried to sell him a 284 bit encrypted program. When Vasovski asked him what he thought of Julian Assange, he replied that he didn't know who that was. "At that point I said, 'you're trying to sell me a computer security program and you don't know who Julian Assange is?'"

Another benefit Vasovski described is lowered costs. With insurance companies acting as the middle man, there is no check on costs because there is no incentive to cut back on costs. Insurance companies earned more the higher the prices, and consumers aren't paying the bill. "So it looks like healthcare costs more, but that's not the true bottom line." In fact employers had to deal with most of the costs of care. "In the price of a new car from GM, like 14-15% of the cost of the car is nothing but health insurance."

Vasovski also said that the off grid system improves the doctor patient relationship. "You do spend a little more time – not less time – you spend more time with them, and by design, you're going to be a little bit more interested in satisfying them than if it's just a checkmark on a sheet with the bill going to the insurance company."

On a more ideological level, the direct payment model also gets back to the true nature of insurance. "If you're dealing with no deductible or a $20 co-pay for a visit or something, it's not really insurance because then it's like going to eat at the Golden Corral. Once you're in you get to eat all you want." People don't use car insurance for oil changes; they use it for wrecks. A $5000 deductible means people can use insurance for any major event – even a broken leg will cost about $10,000 to fix and any emergency room visit will start at $2,500 – while paying $45 for simple visits. A high deductable "turns it into real insurance. It's only used when there is something really bad, and the rest of the stuff you have to pick up on your own. Then you become a very good shopper."

Dr. Vasovski eliminated the insurance aspect of his practice because he could provide better care cheaper on a free market system. Many doctors who are currently deliberating whether to keep their practices open may choose to convert to such a system, too. Direct pay programs, along with generic drugs and pharmacy-provided shots and vaccinations, mean that the free market will continue to play a role in healthcare and insurance.

Wall Streets shake up artists such as well know Carl Ichan (I wish I bought Cheesepeake when it was at bottom when he got involved - up from 15 to 27!!!), are scouring other energy companies to do the same thing.

The reason I post here is extracting value is EXACTLY what Wall Street is doing in the health care sector. It seems to be under the radar with AHA taking all the headlines. I am not saying it is good or bad. I am just pointing this out. But this struck me as a very good analogy to what I see in health care:

If you need any indication of just how embarrassed the Obama administration is regarding O'care enrollment numbers, consider this disclosure from reporter Kyle Potter: "The Obama administration asked North Dakota's largest health insurer not to publicize how many people have signed up for health insurance through a new online exchange, a company official says." Potter reveals that "During a Monday forum in Fargo for people interested in signing up for coverage via the exchange, James Nichol of Blue Cross Blue Shield of North Dakota told the crowd his company received the request from the federal government earlier Monday." And for good reason: BCBS spokeswoman Andrea Dinneen shed some light on the figures anyway, saying that only 14 state residents had successfully enrolled since October 1. Press Secretary Jay Carney has repeatedly said that HHS officials will release enrollment figures soon -- as soon as it's politically convenient, that is.=====================

Your Insurance TerminatedHundreds of thousands of Americans across the country are getting cancellation notices from various insurers because their plans don't meet O'care requirements. According to Kaiser Health News, "Florida Blue ... is terminating about 300,000 policies, about 80 percent of its individual policies in the state. Kaiser Permanente in California has sent notices to 160,000 people -- about half of its individual business in the state. Insurer Highmark in Pittsburgh is dropping about 20 percent of its individual market customers, while Independence Blue Cross, the major insurer in Philadelphia, is dropping about 45 percent." Consequently, "the cancellation notices ... have shocked many consumers in light of President Barack Obama's promise that people could keep their plans if they liked them." You get what you vote for -- in Obama's case, empty rhetoric.

O'Care Prices 'Incredibly Misleading'"CBS News has uncovered a serious pricing problem with Healthcare.gov." Uh oh. CBS says that the administration's new "shop and browse" feature sometimes causes customers to pay double the price they see for insurance on the website. The reason is that all comers are divided into two groups: 49 or under and 50 or over. CBS notes, "Prices for everyone in the 49-or-under group are based on what a 27-year-old would pay. In the 50-or-older group, prices are based on what a 50-year-old would pay." Therefore, unless you're 27 or 50, your estimate could be drastically understated. Who knew Hope™ would cost this much.

Dave Macdonald, JD. CEO of Aegle Advisors. There are a number of factors contributing to high-cost hospital environments, which if not dealt with effectively, will continue to drive healthcare costs out of control. The existing organizational structures, productivity expectations and lack of true accountability drive most of the cost. Hospital organizations are not immune to the ever-increasing health insurance and benefit premiums that we see nationally. This tends to be the second-highest cost that a hospital will incur behind salaries and wages. For the last few years, most hospitals have seen double-digit increases in premiums and are often reluctant to pass this increase entirely through to the employees, thus absorbing most of it as an expense. In addition, other benefit costs, like pensions and lucrative time-off allowances, are built into the hospital cost structure, many times driven by union contracts and commitments to employees. However, these costs tend to be higher in comparison to their counterparts in the private sector. Unfortunately, pension costs are difficult to address given the impact to the employees and the political ramifications. In addition, when clinical employees take time off, there is often replacement costs associated with caring for the patients.

All of this is enough to send costs spiraling, but then you add outside forces, such as government agencies for Medicare and Medicaid and third-party payors, and suddenly you've created a system that requires enormous administrative burdens — burdens no other industry is subjected to. Highly skilled and educated providers are constantly being challenged about their clinical decision-making in an effort to slow down payments or completely deny payments to the hospital and or physicians. The cost of redundant systems, and the people and processes to manage multiple systems from different government and private payers, forces hospitals to hire additional staff in order to be compliant with the all of the red tape.

The end result is a high-cost, inefficient healthcare delivery system. Every payor has different rules and/or regulations for a service to be covered and hopefully paid. Both the healthcare organization and the payor have to hire more people to oversee the rules, creating higher premiums and higher administrative costs. Often times, hospitals will have to appeal two to three times simply to get paid for services that were duly earned the day they were performed, not one year from then. Hospitals are forced to spend too much time tracking and chasing payments instead of using their resources to focus on the patient experience and deliver the most efficient and effective care that the patient deserves.

We are losing to Obamacare precisely because everyone correctly intuits the preceding to be true. Obamacare pretends to offer a solution and does so in terms that people think they understand.

What do we offer?

Back during the battles against the passage of Obamacare we noted here that it included a number of ideas that the Reps called for as well as the Dems. Do any of us remember what they were? Shouldn't they be part of the Rep message now?

Apart from whatever these points were, I'm thinking:

As Glenn Beck notes in a post I made this morning on The Way Forward thread, there is much overlap in many of the progressives criticisms and ours. It makes sense to me that we give these criticisms a more prominent part in our messaging-- which as present tends to focus almost exclusively on why the progressives solutions are wrong.

a) price transparency of health care-- in a way that the government has a proper role in requiring that contents of the box that we are buying be what they are in the amount alleged and not other stuff being in there, is there a role for the government to require that prices be readily known in advance? Without this, how can there be a free market?

b) one national market-- why do we have 50 markets at present?

c) One of the reasons that Obamacare is so expensive is that it requires so many things so many people do not want-- but if we are to have people choose what coverage they do want, the companies must put out their information in a comprehensible manner. Is there a government role for standardizing how the information is to be presented so as to enable comparisons?

Many medical practitioners have apparently simply had enough. Instead of continuing their never-ending struggle with the welfare state's red tape, they have decided to revert to a free market model without insurance. At first glance that seems to represent a barrier to obtaining medical care for poorer strata of the population. However, a second glance reveals that this might actually not be the case. No doubt to the great dismay of the sick-care cartel and the bureaucracy administering it, the refreshing breeze of the free market suddenly intruding upon the system shows what prices actually would be if the State were not involved in health care. According to a recent report on the spreading 'cash only' medical care phenomenon:

“Fed up with declining payments and rising red tape, a small but growing number of doctors are opting out of the insurance system completely. They’re expecting patients to pony up with cash. Some doctors who have gone that route love it, saying they can spend more time with and provide higher-quality care to their patients. Health advocates are skeptical, worrying that only the wealthy will benefit from this system.

In Wichita, Kansas, 32-year old family physician Doug Nunamaker switched to a cash-only basis in 2010 after taking insurance for five years. (“Cash-only” is a loose description. Nunamaker accepts payment by debit or credit card too.)

[..]

Under the traditional health insurance system, a large staff was required just to navigate all the paperwork, he said. That resulted in high overhead, forcing doctors like Nunamaker to take on more patients to cover costs. Plus, the amount insurance companies were willing to pay for procedures was declining, leading to a vicious cycle. “The paperwork, the hassles, it just got to be overwhelming,” Nunamaker said. “We knew that we had to find a better way to practice.”

So Nunamaker and his partner set up a membership-based practice called Atlas M.D. — a nod to free-market champion Ayn Rand’s book Atlas Shrugged. Under the membership plan — also known as “concierge” medicine — each patient pays a flat monthly fee to have unlimited access to the doctors and any service they can provide in the office, such as EKGs or stitches.

The fee varies depending on age. For kids, it’s $10 a month. For adults up to age 44, it’s $50 a month. Senior citizens pay $100.

The office has negotiated deals for services outside the office. By cutting out the middleman, Nunamaker said he can get a cholesterol test done for $3, versus the $90 the lab company he works with once billed to insurance carriers. An MRI can be had for $400, compared to a typical billed rate of $2,000 or more.

[…]

Kevin Petersen, a Las Vegas-based general surgeon, stopped taking insurance in 2005. Petersen named the same reasons as Nunamaker: too much paperwork and overhead, declining payments from insurance companies, and a general loss of control. “The insurance industry took over my practice,” he said. “They were telling me what procedures I could do, who I could treat — I basically became their employee.”

Now Petersen does hernia operations for $5,000 a pop, which includes anesthesia, operating room time and follow-up visits. He negotiates special rates for the anesthesiologist and the operating room, and is able to provide the service for about a third of what a patient might pay otherwise.

Many of his patients are early retirees who are not yet eligible for Medicare but can’t afford a full-fledged health insurance plan, he said, and business is booming. “My practice at this point is the best it’s been in my 26-year career,” he said. “By far.”

While the cash-only model may please doctors, some question whether it’s good for middle- and low-income people. Kathleen Stoll, director of health policy at the consumer advocacy group Families U.S.A., didn’t want to speak directly to either Petersen’s or Nunamaker’s practice, as she didn’t know the specifics of each.But in general, she fears that doctors who switch to a cash-only model will drive away the patients who can’t afford a monthly membership fee or thousands of dollars for an operation. “They cherry-pick among their patient population to serve only the wealthier ones,” Stoll said. “It certainly creates a barrier to care.”

(emphasis added)

Obviously, both the named and unnamed 'health advocates' and worriers have it completely wrong. People who don't have to pay thousands of dollars for health insurance actually can afford 'thousands of dollars for an operation' that costs only one third of what it would otherwise cost. It is not only the wealthy who can afford this free market care (besides, people who don't want it have the option to continue with the existing system).

Look at those prices! A cholesterol test for “$3 instead of $90” – that is more than 96% less! An MRI for $400 instead of “$2,000 or more” (usually will be 'or more')? Not to mention the fact that these doctors now have more time to actually care for their patients properly. What's not to like.

A Win-Win By Mistake?

Imagine for a moment what might happen if the government were to get out of healthcare altogether and there would be free competition between all health care service providers. What would happen to prices in that case? It is probably fair to assume that they would come down precipitously even from the low prices free market doctors are already able to obtain for their patients nowadays.

It is actually a good bet that the onerous red tape and the likely explosion in costs due to Obamacare will accelerate the move toward a free market in health care – unless the government explicitly forbids it, that is (unfortunately we cannot rule out completely that such tyrannical steps will eventually be taken – the government generally doesn't like it when its 'help' is refused).

If so, the Obamacare Act could turn out to become a win-win by mistake so to speak, as more and more people decide to opt out of the system. It seems clear that the free market solution is preferable to the cartelized health care system imposed by government and the lobbyists that have co-written the laws. The doctors portrayed in the article above are leading by example, and we expect their ranks to swell in coming years.